Applicability of the Fagerström Test for Nicotine Dependence in smokers with schizophrenia

Up to 90% of individuals with schizophrenia smoke cigarettes, and many show signs of heavy dependence. Although the severity of nicotine dependence is often measured by the six-item Fagerstrom Test for Nicotine Dependence (FTND), this measure, in its current form, may not be as appropriate in this population--or in others who's smoking is regulated by others--as in the general population due to differences in smoking patterns, living arrangements, and daily routines. These factors may produce an underestimate of nicotine dependence, which may have clinical implications for successful medical detoxification if the FTND scores are used to guide the dosage of nicotine replacement medication. Data indicate poor internal consistency reliability (alpha=.4581) and a factor pattern lacking simple structure (i.e., two nonmeaningful factors/components with substantial cross loadings) when administered to smokers with schizophrenia. Specific examples of problematic items and how these may contribute to an underestimate of tobacco dependence severity are discussed, as well as ways to modify the FTND to be more appropriate for this population.     

Cognitive interviews for measurement evaluation of the Fagerström Test for Nicotine Dependence (FTND) in smokers with schizophrenia spectrum disorders

People diagnosed with schizophrenia have among the highest known rates of tobacco use. While the Fagerström Test for Nicotine Dependence (FTND) is the most widely used measure of nicotine dependence, recent research has questioned its applicability for individuals with schizophrenia. The current study employed cognitive interviews to evaluate the FTND with smokers diagnosed with schizophrenia spectrum disorders, recruited from an acute inpatient psychiatry setting, and a comparison group of smokers recruited from the community. The groups were comparable on tobacco use variables and FTND scores. Detailed qualitative cognitive interviews indicated all subjects understood the FTND items. For both groups, the FTND missed nocturnal smoking, reported as weekly by 80% of patients and 47% of controls. Finishing other people's cigarettes also was under-reported on the FTND. Restrictions to smoking were common across groups. The cognitive interview methodology proved useful for understanding how individuals interpreted and answered the FTND items. Overall, the qualitative findings identified limitations in the FTND for both groups, with the limitations generally more pronounced among patients with schizophrenia.     

The Fagerström Test for Nicotine Dependence in a Dutch sample of daily smokers and ex-smokers

We explored the performance of the Fagerström Test for Nicotine Dependence (FTND) in a sample of 1378 daily smokers and 1058 ex-smokers who participated in a survey study of the Netherlands Twin Register. FTND scores were higher for smokers than for ex-smokers. Nicotine dependence level was not associated with age. FTND score was highly correlated with the maximum number of cigarettes smoked (even after excluding the item ‘number of cigarettes per day’ from FTND), but the FTND score showed a low correlation with age of first cigarette and total number of years smoked. In a subsample of smokers (n=143) and ex-smokers (n=181) the test–retest correlations for the FTND were high. In general, the performance of the FTND in ex-smokers was comparable with that in smokers. These findings suggest the FTND to be a valuable tool for studies of nicotine dependence in large epidemiological samples.     

Comparing the validity of the Cigarette Dependence Scale and the Fagerström Test for Nicotine Dependence

BACKGROUND: We compared the validity of the Cigarette Dependence Scale (CDS-12) and of the Fagerstr?m Test for Nicotine Dependence (FTND) in daily cigarette smokers. METHODS: Internet survey in 2004-2007. Eight days and 6 weeks after answering these two dependence questionnaires, participants indicated their smoking status and answered the Cigarette Withdrawal Scale and the Smoking Self-Efficacy Questionnaire. We used the Mini International Neuropsychiatric Interview (MINI) to assess nicotine dependence as defined in DSM-IV. RESULTS: There were 13,697 participants at baseline, 1113 (8%) after 8 days and 435 (3%) after 6 weeks. CDS-12, but not FTND, predicted smoking cessation after 8 days (odds ratio=1.20 per standard deviation unit, p=0.03) and 6 weeks (odds ratio=1.34, p=0.01). In participants who had quit smoking after 8 days, CDS-12 was a better predictor of craving (beta=0.30, p<0.001), than FTND (beta=0.14, p<0.01). After 8 days, self-efficacy in quitters was predicted by CDS-12 (beta=-0.16, p=0.02), but not by FTND (beta=-0.05, p=0.3). CDS-12 was more strongly associated than FTND with DSM-defined dependence measured by MINI: area under the Receiver Operating Characteristic (ROC) curve=0.72 (95% confidence interval=0.70-0.73). For FTND, the area under ROC=0.64 (0.63-0.66). CONCLUSIONS: CDS-12 performed better than FTND on tests of predictive and construct validity.     

A short form of the Fagerström Test for Nicotine Dependence and the Heaviness of Smoking Index in two adult population samples

Few data exist about the Fagerstr?m Test for Nicotine Dependence (FTND) and the Heaviness of Smoking Index (HSI) from population samples. The goal was to prove to what degree (1) a reduced item solution of the FTND and (2) the HSI represent the FTND. Two randomized adult population samples were used from northern Germany. Sample 1 included 1462 and sample 2 included 1042 current daily cigarette smokers aged 20-64 years with FTND data. The results show that four items of the FTND as well as the HSI represent the FTND. It is concluded that both are valid measures of the urge to smoke and the tobacco-smoke-seeking behavior.     

An Examination of the Fagerström Test for Nicotine Dependence Among Concurrent Tobacco and Khat Users

Abstract

The current study examined the psychometric properties of the Fagerström Test for Nicotine Dependence (FTND) among tobacco smokers who use khat (Catha edulis), a widely used substance in East Africa and Arabian Peninsula. We also explored gender differences in response to FTND items because little attention has been paid to women's smoking behavior in Middle Eastern societies. A total of 103 (38 women) concurrent users (mean age ± SD: 24.4 ± 5.2) were recruited from two universities in Yemen. An Arabic version of FTND was developed using back-translation method. Chronbach's alpha was used to examine the reliability and principal component analysis was conducted to test the factor structure of the scale. The scale was found to have low internal consistency reliability (Chronbach's α = .58). Two factors were identified, accounting for 57% of the total variance. A series of chi-square analyses found that men indicated more symptoms associated with nicotine dependence than women (ps < .05). Although the poor reliability observed in the present sample argues for a cautious approach when assessing nicotine dependence among khat users, the findings on factor structure and gender differences may provide support for the validity of the scale. Taking into account sociocultural factors associated with patterns of smoking behavior among this population should improve the psychometric properties of FTND.     

Reliability of the Fagerström Test for Nicotine Dependence, Minnesota Nicotine Withdrawal Scale, and Tiffany Questionnaire for Smoking Urges in smokers with and without schizophrenia

Few studies have examined the psychometrics of smoking-related behavioral measures in schizophrenia and questions have been raised about the applicability to smokers with schizophrenia. We examined the reliability of the Fagerström Test for Nicotine Dependence (FTND), Minnesota Nicotine Withdrawal Scale (M-NWS), and the Tiffany Questionnaire for Smoking Urges (TQSU) for smokers with schizophrenia (SS; n = 151) and nonpsychiatric smokers (CS; n = 181) recruited into three studies with similar inclusion criteria. SS and CS did not differ on a number of demographic and smoking variables (e.g., age). SS reported higher carbon monoxide (CO) levels, plasma cotinine levels, FTND, M-NWS, and TQSU Factor 1 scores. The internal consistencies (Cronbach's α) of the smoking measures were found to be high and comparable between diagnostic groups for the FTND, M-NWS total scores, and TQSU Factor 2 (all α's > 0.70) but higher for the CS than SS for the TQSU Factor 1 (0.86 versus 0.79). Test–retest correlations were lower for SS than CS on the FTND (0.65 versus 0.82), TQSU Factor 1 (0.65 versus 0.79), and TQSU Factor 2 (0.69 versus 0.81), but did not differ between diagnostic groups for M-NWS (0.58 versus 0.64). Our findings suggest that these measures may be reliable for use in smokers with schizophrenia.     

Association of withdrawal features with nicotine dependence as measured by the Fagerström Test for Nicotine Dependence (FTND)

The aim of this study was to advance our understanding of how nicotine dependence level, defined by the Fagerström Test of Nicotine Dependence (FTND), relates to nicotine withdrawal features. We classified nicotine dependence in two categories, 1) low dependence (LD; FTND < 4) and 2) high dependence (HD; FTND ≥ 4). A sample of 241 smokers was recruited via newspaper ads and public notices. Using a multivariate response model with adjustments for age, sex, age at first cigarette, race, and current or lifetime depression, we observed a small to modest statistically robust association between nicotine dependence level and withdrawal features such as, irritation/anger (adjusted relative risk, aRR = 1.2; 95% CI 1.0, 1.3); nervousness (aRR = 1.3; 95% CI 1.1, 1.6); restlessness (aRR = 1.2; 95% CI 1.1, 1.4); difficulty concentrating (aRR = 1.3; 95% CI 1.1, 1.7); and trouble sleeping (aRR = 1.8; 95% CI 1.2, 2.6). Our findings are consistent with the inference that the FTND measures “physiological dependence” and that multidimensional approaches are needed to capture the full range of smoking phenotypology.     

The Fagerström Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST)

Few nicotine dependence measures have been developed for smokeless tobacco (ST) users. Existing measures are limited by the requirement to rate the nicotine content of ST brands for which data is scarce or non-existent. We modified the Fagerström Test for Nicotine Dependence (FTND) for ST users, referred to this scale as the FTND-ST, and evaluated its characteristics in a population of 42 ST users. The correlation between the FTND-ST total score and the serum cotinine concentrations was 0.53 (p < 0.001). Internal consistency reliability assessed using the coefficient alpha was 0.47. Correlations and the coefficient alpha are similar to those reported for commonly used nicotine dependence measures. Development and refinement of nicotine dependence measures for ST users are essential steps in order to advance the field of ST research.     

Consistency or change in nicotine dependence according to the Fagerström Test for Nicotine Dependence over three years in a population sample

The goal was to determine whether nicotine dependence levels remain consistent or change over three years. From a population- based sample of 4075 residents aged 18-64, drawn at random, data of 696 individuals was used, who had smoked cigarettes for 21 years on average. Nicotine dependence was assessed by the Fagerstr?m Test for Nicotine Dependence (FTND) at baseline, and 30 and 36 months later. In addition, nicotine dependence and alcohol dependence were diagnosed according to the American Psychiatric Association (DSM-IV). We found an increase in the FTND over 36 months. Subgroups were revealed with sustained high, increasing, decreasing, and sustained low rates of the FTND sum score. Male gender, age at onset of smoking 15 years or younger, DSM-IV nicotine dependence, and DSM-IV alcohol dependence at baseline predicted a sustained high FTND. We conclude that nicotine dependence is increasing even after many years of smoking in an adult population sample.     

Measurement properties of the Fagerström Test for nicotine dependence adapted for use in an adolescent sample

This study uses confirmatory factor analysis to test the factor structure of a modified version of the Fagerstr?m Test for Nicotine Dependence (FTND) in an adolescent sample. Specifically, we test the fit of a two-factor model specification as well as a single-factor solution. This study uses methods that are appropriate to the categorical nature of the items making up the FTND and is the first study to examine the measurement properties of the FTND in a large adolescent sample. Both the two-factor and single-factor model specifications achieved acceptable model fit. It should be noted that these study results speak to the dimensionality of the FTND and not to the dimensionality of a general nicotine dependence construct in adolescents.     

A comparison of the psychometric properties of the hooked on nicotine checklist and the modified Fagerström tolerance questionnaire

We compared the psychometric properties of the Hooked on Nicotine Checklist (HONC) and the Modified Fagerström Tolerance Questionnaire (MFTQ). Adolescent current smokers (n = 215) completed both instruments three times, at baseline and 6- and 12-month follow-up. Internal consistency of the HONC was high (α = 0.92), as was its stability over the follow-up interval (intraclass correlation (ICC) = 0.93 over 6 months and 0.91 over 1 year). Internal consistency of the MFTQ was acceptable (α = 0.83), and its stability over the follow-up interval was similar to that reported previously (ICC = 0.79 at 6 months and 0.76 at 1 year). The HONC predicted smoking at both follow-up points, while the MFTQ did so only at 6 months. The HONC compared favorably with the MFTQ in all respects. The most important advantage of the HONC is that it is measuring a clearly defined concept, diminished autonomy over tobacco, which begins when the sequelae of tobacco use present a barrier to quitting.     

The Fagerstrom Test for Nicotine Dependence and the Diagnostic Interview Schedule: do they diagnose the same smokers?

Two common assessment tools for nicotine dependence are the Fagerstrom Test for Nicotine Dependence (FTND) and the Nicotine Dependence section of the Diagnostic Interview Schedule [(DIS)-III-R or -IV based on the Diagnostic and Statistical Manual (DSM)-III-R and -IV, respectively]. The FTND emphasizes morning smoking and overall "heaviness" of smoking. The DSM emphasizes adverse consequences, desire to cut down, and mood changes during withdrawal. We tested (1) how the DSM-III-R diagnosis of Nicotine Dependence is related to FTND score; and (2) how the (a) DSM-III-R or (b) elevated FTND score is related to longer smoking histories, greater psychiatric symptomatology, and tobacco liking scores. Retrospective chart reviews were conducted on 370 smokers, the majority (55.9%) of whom had a current DSM-III-R diagnosis of Substance Dependence other than nicotine. All subjects had completed the FTND, the DIS-III-R, the Symptom Checklist-90-Revised (SCL-90-R), and a survey on drug liking. Agreement statistics were calculated between the DSM-II-R diagnosis of Nicotine Dependence and various cutoff scores values that were assigned as thresholds for nicotine dependence on the FTND. At no cutoff score did the two instruments reliably agree; the highest kappa (at a cutoff of FTND > or = 7) was 0.205. At cutoffs above 5, the FTND diagnosed fewer cases than the DSM-III-R. Multiple regression analysis showed that DSM diagnosis was associated with greater psychiatric symptomatology on the SCL-90-R, while FTND scores were associated with greater tobacco liking. The FTND and the DSM-III-R appear to measure different aspects of the tobacco dependence process. Specifically, the FTND may provide a stronger measure of physical dependence, while the DSM may tap other domains such as awareness of dependence, behaviors resulting from that awareness, and psychiatric symptomatology. Disagreements between the FTND and the DSM are likely to become greater with the changes in the DSM-IV.     

A comparison of the autonomy over tobacco scale and the Fagerström test for nicotine dependence

The Autonomy over Tobacco Scale (AUTOS) is a 12-item theory-based instrument used to measure tobacco dependence in smokers. It provides separate measures of three factors that make smoking cessation more difficult: withdrawal symptoms, psychological dependence, and cue-induced urges to use tobacco. We compared the internal reliability and concurrent validity of the AUTOS to those of the Fagerström Test for Nicotine Dependence (FTND). Adult current smokers (n = 422; 62% female; 86.8% white; mean age 33.3 years, SD = 13.7; 57% daily smokers) completed an anonymous web-based survey that included the AUTOS, the FTND and 11 smoking-related behavioral measures. Cronbach's α was .94 for the AUTOS and α > .75 for each of the 3 subscales; α = .73 for the FTND. The AUTOS and its subscales correlated with all measures of concurrent validity (r = .70 between AUTOS &; FTND). The AUTOS correlated better than the FTND with the Hooked on Nicotine Checklist, the longest period of abstinence, latency to wanting, percentage of time a person smokes because of momentary need, pleasure from smoking, days smoked per month, and concern about deprivation. The measures showed similar correlations with the latencies to craving and needing. The FTND correlated better with the duration of smoking and cigarettes smoked per day. Based on these results and those from prior studies, we conclude that the AUTOS offers researchers a valid and highly reliable, theory-based measure that is more versatile in its applications than the FTND.     

A comparison of the content-, construct- and predictive validity of the cigarette dependence scale and the Fagerström test for nicotine dependence

BACKGROUND: Research showed that the widely used Fagerstrom test for nicotine dependence (FTND) does not cover important aspects of dependence. A new test, the cigarette dependence scale (CDS-12), covers the main elements in DSM-IV and ICD-10 definitions of dependence. We compared the psychometrics of CDS-12, FTND, and CDS-5 and the heaviness of smoking index (HSI), which are short versions of CDS-12 and FTND, respectively. METHODS: Internet survey in 2002-2003. Participants were invited one month after answering the first survey to answer a second survey on smoking status and withdrawal symptoms. RESULTS: Eight hundred two smokers answered both surveys. Cronbach's alpha coefficients were higher for CDS-12 (0.91) and CDS-5 (0.77) than for FTND (0.68) and HSI (0.63). Among 231 smokers who quit smoking at follow-up, higher baseline CDS-12 scores predicted higher withdrawal ratings at follow-up, for all withdrawal symptoms except appetite. FTND and HSI predicted higher craving in quitters, but did not predict the intensity of other withdrawal symptoms. Neither CDS-5, FTND or HSI predicted smoking cessation, but higher CDS-12 scores marginally predicted smoking cessation at follow-up (area under the receiver operating characteristic (ROC) curve = 0.55, 95% confidence interval = 0.51-0.59). CONCLUSIONS: CDS-12 had better content validity and internal consistency than FTND and was a slightly better predictor of withdrawal symptoms. Unexpectedly, higher (not lower) CDS-12 scores predicted subsequent smoking cessation, perhaps because endorsement of some CDS-12 items implies accepting that one is dependent, which in turn could reflect motivation to quit. CDS-12 may represent an alternative to FTND for measuring cigarette dependence.     

The Fagerström test for nicotine dependence in two adult population samples-potential influence of lifetime amount of tobacco smoked on the degree of dependence

BACKGROUND: The Fagerstr?m test for nicotine dependence (FTND) has been widely used in clinical samples but seldom in population samples. Data are particularly lacking for a large range of ages. The goal was to describe the FTND sum score distribution in the adult population and to show potential variation according to the number of years of smoking. METHODS: Random adult population samples from two northern areas in Germany were used. Sample 1 included 1460 current smokers aged 20-64 years and sample 2 included 1135 current smokers aged 20-79 years. One cross-sectional and longitudinal and one cross-sectional study were conducted. The FTND was administered during face-to-face computer-aided interviews. RESULTS: The mean FTND sum score for those aged 20-64 was 3.2 among sample 1 and 2.5 among sample 2. The number of years of smoking and age did not affect the FTND sum score whereas it was positively correlated with the lifetime amount of tobacco smoked. CONCLUSIONS: Dependence according to the FTND does not increase with the number of years of smoking. Population-based interventions addressing the needs of dependent smokers across all age groups are needed.     

Validation of the modified Fagerström tolerance questionnaire with salivary cotinine among adolescents

This study was conducted to gain evidence of validity for a nicotine dependence measure for adolescent smokers. We hypothesized that the individual item responses and the total Fagerstr?m Tolerance Questionnaire (FTQ) score would be positively correlated with cotinine values. We examined the relationship between a seven-item modified FTQ and saliva continine among 131 adolescent volunteers in a smoking cessation program. As anticipated, the total FTQ score was related to saliva cotinine (r = .40, p < .01), as were six of the seven individual FTQ items (p < .05). Our findings provide preliminary evidence that the modified FTQ scale is valid and applicable to adolescent smokers.     

Influence of δ-Opioid Receptors in the Behavioral Effects of Nicotine

Multiple studies in animal models and humans suggest that the endogenous opioid system is an important neurobiological substrate for nicotine addictive properties. In this study, we evaluated the participation of δ-opioid receptors in different behavioral responses of nicotine by using δ-opioid receptor knockout mice. Acute nicotine administration induced hypolocomotion and antinociception in wild-type mice, which were similar in knockout animals. The development of tolerance to nicotine-induced antinociception was also similar in both genotypes. In agreement, the expression and functional activity of δ-opioid receptors were not modified in the different layers of the spinal cord and brain areas evaluated after chronic nicotine treatment. The somatic manifestation of the nicotine withdrawal syndrome precipitated by mecamylamine was also similar in wild-type and δ-opioid receptor knockout mice. In contrast, nicotine induced a conditioned place preference in wild-type animals that was abolished in knockout mice. Moreover, a lower percentage of acquisition of intravenous nicotine self-administration was observed in mice lacking δ-opioid receptors as well as in wild-type mice treated with the selective δ-opioid receptor antagonist naltrindole. Accordingly, in-vivo microdialysis studies revealed that the enhancement in dopamine extracellular levels induced by nicotine in the nucleus accumbens was reduced in mutant mice. In summary, the present results show that δ-opioid receptors are involved in the modulation of nicotine rewarding effects. However, this opioid receptor does not participate either in several acute effects of nicotine or in the development of tolerance and physical dependence induced by chronic nicotine administration.     

The Fagerström test for nicotine dependence: a comparison of standard scoring and latent class analysis approaches

Frequent symptom self-monitoring protocols have become popular tools in the addiction field. Interactive Voice Response (IVR) is a telephone monitoring system that has been shown to be feasible for collecting frequent self-reports from a variety of research populations. Little is known, however, about the feasibility of using IVR monitoring in clinical samples, and few controlled trials exist assessing the impact of any type of frequent self-report monitoring on the behaviors monitored. This pilot study with patients in early recovery from an alcohol use disorder (n=98) evaluated compliance with two IVR monitoring protocols, subjective experiences with monitoring, and change in symptoms associated with monitoring (i.e., measurement reactivity). Participants were randomly assigned to call an IVR system daily for 28 days, once per week for 4 weeks, or only to complete 28-day follow-up assessment including retrospective drinking reports. Monitoring calls assessed alcohol craving, substance use, emotional well-being, and PTSD symptoms. Most monitoring participants completed calls on at least 75% of scheduled days (72.2% and 59.2% for daily and weekly, respectively). Including reconstructed data from follow-up of missed calls yielded 77.8% and 74.1% of maximum data points, respectively. Most monitoring participants indicated the protocol was manageable and reported positive or no effects of monitoring on urges to use alcohol, actual drinking, and PTSD symptoms. Analyses of measurement reactivity based on assessment one month after randomization found no significant group differences on drinking, craving for alcohol, or PTSD-related symptoms. Results suggest that IVR technology is feasible and appropriate for telephone symptom monitoring in similar clinical samples.